Pengkajian Keperawatan Kritis

PROGRAM STUDI ILMU KEPERAWATAN SEKOLAH TINGGI ILMU KESEHATAN AVICENNA KENDARI

REKAM ASUHAN KEPERAWATAN (KEPERAWATAN KRITIS)

PENGKAJIAN

I.

Nama

IDENTITAS PASIEN

: ............................... ............... ........................ ........

H"#. Dgn Pa$%en! ............................

Umur : ........... ........... Thn/Bln/Hr *) J.Kelamin: Laki-Laki / Perempuan *) St. Perkawinan: Kawin/Belum*)

K%%man Da%

Suku/Ban!a: ................... ............................ .............. .....

Nama Penganta! .............................

T&! ......................

! ............... ..............

'M(

 "ama

: ................ .......................... ................. .......

Peker#aan

: ................... ............................ .............. .....

&&! ...................K

A'at &ant" ang %a+a%:

NO RM Pen$i$ikan : ................... ............................ ................. ........  "lamat

: ................. .......................... ................... ............

 

.....................................

Tanal MRS: ........./ ........./ %&.... Jam

: ...............

Tanal Penka#ian: Penka#ian : ....../ ........./ %&.... Jam

: ...............

................................................................................

DIAGNOSIS MEDIS!

II. RIWA RIWA,AT KEPERA KEPERAW WATAN  "la!an Ma!uk RS: ............................................... ......................................................................................... ......................................................................................... .........................................................................................

Keluhan utama Saat ini:............................................ ............................................................................................... ................................................................................................ ............................................................................................... ....................................................................................................

Upa)a ) telah $ilakukan:  ................................................................................................................................................. Riwa)at Pen)akit * pernah $i$erita: Pernah men$erita pen)akit: .......................................................................Kapan: ................................................................ Pernah $i+pera!i: .......................................................................................Kapan: ................................................................. Pernah $irawat $i RS Karena: ................... ............................. ................... ................... ................... ................... ...........Kapan: .Kapan: .................. ...........................La .........Laman)a: man)a: ................... ....................... "leri O,at: .............................. .............. ................................. ................................. ..................... .....

III. III. O&SE O&SERV RVAS ASII DAN DAN  PEMERIKSAAN -ISIK 1.

Keaaan Um"m:

2.

Ke$aaan:

.

........................................................ '+mp+! Menti! "pati! ilirum S+mn+lent S+p+r '+ma

Penaa$an (A%0a 1 &eat2%ng3 &4)

Se!ak Napa!: *a Ti$ak Orth+pn+e Pernapa!an : "$a Ti$ak a$a ')an+!i!: Bi,ir Kuku/Jari-#ari Ti$ak Bentuk a$a: Simetri! Ti$ak Simetri! 0erakan Pernapa!an: 'upin Hi$un See Saw Retrak!i 1nter2+!tal Retrak!i Su,ka3ikula P+la Napa!: 'epat $ankal / alam45 Batuk : Ber$ahak Kerin arah Ti$ak Suara Napa!: 6e!ikuler R+n2hi Kiri/Kanan45 Rale! 7riti+n Ru, 8hee9in Kiri/Kanan45 Lainn)a:...............................  "lat Bantu Napa!: 'anul Na!al Ma!ker Bia!a Ma!ker re,rhitin/N+n Re,rhitin45 OT NT Tra2he+!t+mi Tra2he+! t+mi 6entilat+r  Lainn)a: Lainn)a : ............................ ................ ............ Keluhan Lainn)a: ............................................................... ...........................................................................................

"leri Makanan: Makanan : ............................... .............. ................................. ................................ ........................ ........ . Tana V%ta'! Ten!i : ............. .............mmHg Suhu

: ............... O C

Na$i :  ..................... / Men%t Pernapa!an : ............... / Men%t 5.

Ca%56a$7"'e (&'553&8)

en)ut Na$i: "$a Ti$ak a$a ................................................................................................ N)eri $a$a: Ti$ak *a( Bila *a; Jela!kan:.......... Jela!k an:.................. ........ .............................................................................................. 1rama Na$i: Tertur Ti$ak teratur  Palpita!i Palpita !i : Ti$ak *a Per $etik J6P : =? 2m >? 2m Bun)i Jantun: S@/S% Murni /",n+rmal S S Murmur 0all+p Thrill A$ema: "na!arka Palpe,ra Atremita! ata! Atremita! ,awah  "kti3ita! era#at : 1 11 111 16 Keluhan Lainn)a: ................................................................ ..............................................................................................

C.

Pe$aa9an (&a%n3&:)

7.

Ke2uriaan
Ti$ak

*a

 Pe+em%2an  E'%m%na$% U% (&'ee3&;)

Pr+$ urine: ............mlG ........../hariG Oliuri/"nuri/P+liuri45 Reten!i urine 1nk+ntinen!ia Urine

Jela!kan:............................................................................ 0'S: A: ............ 6: .............. M: .............. T+tal: ........... Re
i!uria:

Ukuran: ..............E............mm Re
Ti$ak

*a( Bila *a; Jela!kan:.......................

.............................................................................................. 8arna Urine: ...............................................G Hematuri Palpa!i: 0in#al: Tera,a / Ti$ak Tera,a45 6e!ika Urinaria: K+!+n Lunak Kera! 0enitalia: Sirkum / T$k Sirkum Priapi!mu! Hip+!pa$ia Api!pa$ia 7im+!i! Kript+ki!mu! Blaniti! Hernia 6erik+kel

Keluhan Lainn)a: ............................................................... ...........................................................................................

.............................................................................................. Keluhan Lainn)a: ............................................................... ........................................................................................... .

Pen7enaan E'%m%na$% A'6% (&50e'3&<)

Keluhan:

Mual

Kuran/Ti$ak a$a na
Muntah: .........Kali D................................................5 N)eri ",$+men:

Ti$ak

*a( Bila *a; Jela!kan:..........

9.

M"$+"'5$+e'eta'Integ"men (&5ne3&=)

Keluhan N)eri:

Ti$ak

*a( Bila *a; Jela!kan:..........

.............................................................................................

............................................................................................. . Beka! Luka Opera!i: Ti$ak *aG ...............................

7raktur :

Bi!in U!u!: ........... I/menitG Peri!taltik: ............................... Perku!i: T)mpani H)pertimpani Pekak Palpa!i: Hepar DTi$ak Tera,a/Tera,a5 Ukuran .................... LimpaDTi$ak Tera,a/Tera,a5 Ukuran .................... Ma!!a DTi$ak Tera,a/Tera,a5 Ukuran ...................

Pererakan Sen$i: Be,a! e<+rmita!: : Ti$ak *a Kekuatan Ot+t:

B"B: ................. I/HariG K+n!i!ten!i: ............................... iare K+n!tipa!i 7ae2e! Ber$arah Melena Re2tum:............................................................................... Keluhan Lainn)a: ............................................................... ...........................................................................................

Ti$ak

*a( Bila *a; Jela!kan:.......................

..............................................................................................

Luka: :

Ti$ak

Ter,ata!G............................. "tr+pi K+ntraktur 

*a( Bila *a; Jela!kan:.......................

.............................................................................................. Ke$aan Kulit: ....................................................................... .............................................................................................. Tur+r : Baik 'ukup Menurun/Jelek Keluhan Lainn)a: ............................................................... ...........................................................................................

IV.TERAPI ( Tulis Tanggal) 

V. PEMERIKSAAN PENUNJANG ( Tulis Tanggal)  (Peme%+$aan La#5at5%"m> Ra%5'5g%> EKG an Peme%+$aan Pen"n?ang La%nna)